As part of the Authority’s investigation into the cause of an August 6th derailment, WMATA’s technical incident report to the Interim General Manager was released to the public today. The report will be the subject of a special Board of Directors Safety Committee Meeting on September 3. The FULL report is available at this link (PDF).
“While the safety investigation is continuing and subject to review by the Tri-State Oversight Committee (TOC), the operations report reveals that the physical root cause of the derailment was the failure of fasteners to properly hold the rail securely. This was compounded by a lack of systematic, immediate review of data generated during the inspection vehicle runs,” said Safety Committee Chairman Michael Goldman speaking on behalf of the Board. “The investigation is ongoing to determine what caused those fasteners to fail. Further, the wide gauge track condition that went unrepaired was a contributory factor leading to the derailment that should never have occurred.”
According to the Incident Report, a Metro employee operating the Track Geometry Vehicle (TGV) that identified a “Level Black’ rail defect on July 9th mistakenly deleted the information about the defect from the exception report. That report was given to maintenance crews for scheduling immediate repairs to the rail system. Under the then-established protocols, the employee’s report with erroneously-deleted information was not subject to review by any Metro supervisor. The underlying data was not analyzed by other Metro departments for errors until after the derailment occurred on August 6.
“In reviewing the TGV inspection process, we have learned that the derailment was caused by a combination of human error and flawed Metro processes,” Goldman said. “While the employee believed he was deleting a routinely detected anomaly and not an actual rail defect, that such a serious error went undetected with no checks and balances in place reveals gaps in Metro’s safety policies and procedures.”
Still under investigation by Metro’s Safety Department is why the wide gauge condition and the broken fasteners went undetected by Metro track walkers who inspected this area of track on multiple occasions between the TGV run on July 9 and the August 6 derailment.
The Report also documents the immediate actions Metro has taken since August 6 to assure the safety of its passengers. Those include comprehensive inspections and immediate repairs of defects, the thorough review of the track inspection vehicle’s test results with an area manager prior to the generation of the final report for the maintenance crews, making track walker inspections more robust, and engineering reviews by outside experts.
In order to prevent such track safety failures from occurring in the future, the Board’s Safety Committee will review management’s actions and additional process and policy changes, as well as consider the need for “beefed up” safety reporting and consideration of protocols in other safety-critical areas to ensure maintenance crews have the most reliable information possible in order to schedule critical repairs. Further, the Committee will review how effectively the Authority’s System Safety Plan is meeting the safety culture needs of the organization and will examine if sufficient resources are available to meet the priority infrastructure inspection and maintenance requirements.
To view questions and answers about this report, please click this link.